Health reform hits abortion wall

With congressional committees having entered the phase of proposing specific legislative language for health reform, an old problem has resurfaced: health reform and abortion rights are on a collision course. I refer to it as an old problem because it is one of the issues I dealt with when serving in the Clinton administration during the last effort to achieve universal coverage. We struggled then to devise mechanisms that would preserve choices for both sides. The threat to the overall reform effort never became visible, though, because reform crashed for other reasons before public attention focused on that level of detail. The good news this year is that we seem to be far enough along that abortion has become a meaningful concern.

There are three contexts in which inclusion of abortion is relevant: the structure of a public option plan, the basic benefits package that all private group health insurance plans would have to include, and the use of public subsidies to defray premium costs for low-wage workers and others who need assistance. In each case, conservatives frame the question, as a recent NY Times article did, as the use of public funds to finance programs that include access to abortion.

That framing hides some harsh realities. One is that if a basic benefits package barred coverage for abortion, women who now have coverage through their workplace (or other) health insurance would lose it. That would amount to a massive cutback in access to choice for tens of millions of women. Here’s the way the issue should be framed, straight out of my notes from 1993:

It is essential to maintain the existing coverage and access to services that women now have under private health insurance plans; and

The basic benefit packagedesign must include all pregnancy-related services that are medically necessary and/or appropriate.

You can expect that most reporting of this debate will treat it as one more example of how the crazy wild card issue of abortion screws up rational political deliberation. It goes deeper than that, though. The abortion problem in health reform exemplifies the way that sexuality-related questions privatize our political discourse. And, like the Hyde Amendment with which it resonates, it’s a morality debate that is likely to get resolved by a compromise deal cut on the backs of the poor – specifically, inscribed on the bodies of poor women. No public funds for abortion involves a tiny number of dollars (the 1993 estimate was that abortion services accounted for 0.3 per cent of the average insurance premium), but the amount looms large for the individual woman who needs it.